The challenge of multimorbidity: A qualitative study of general practitioners' management of patients with multimorbidity

Abstract

Background: It is well know that people with multimorbidity constitute a growing group of patients, causing challenges for the patients, who experience disease- and treatment burdens, as well as for the health care system, which is confronted by economic and organizational challenges. In spite of that knowledge about how best to manage multimorbidity and how to improve health care among these patients is still limited. The increasing number of patients with multimorbidity is also felt in general practice where managing multimorbidity is a daily task for most general practitioners. As coordinators for the patients the GPs function as entrance to the health care system, and a growing interest in general practitioners' experiences with managing multimorbidity is found. However, existing studies mainly focus on challenges such as increased workload burden or disorganized and fragmented care as a result of the complexity multimorbidity constitute, and barriers to appropriate management of multimorbidity is emphasized. The present study expands the subject field by studying the GPs actual ‘doings’ in relation to their ‘sayings’, thus providing nuances in what characterize management of multimorbidity in clinical practice of the GPs and as such the study point out characteristics in general practice which promote appropriate management of patients with multimorbidity. Aim: To explore general practitioners experiences with and perspectives of management of patients with multimorbidity. Methods: Ethnographic study using participant-observation, semi-structured interviews and focus group discussions in three different general practices. Interpretive description was used as analytical framework. Results: Overall the study found that the GPs value their work with patients with multimorbidity and they find it professionally and personally interesting due to the complexity of these patients. Also, the study shows that the term 'multimorbidity' is not an adequate category in practice of the GPs. The variation in disease course among these patients is not related to the number or combination of diseases. Rather the GPs approach is holistic, based on an individualized approach and on the functional ability associated with the patient's everyday life. Specific, the following components were identified as pivotal for how the GPs act in relation to their patients with multimorbidity: individualized and personalized focus; holistic view of the patient's situation; long-term knowledge of the patient; functional ability in relation to everyday life, facilitator for the patient. All though such characteristics are fundamental for the GPs work they become especially significant in relation to patients with multimorbidity because they accommodate the complexity of needs and treatments among these patients. These features are thus critical for the GPs options for managing the complexity characterizing this group of patients. Conclusion: The study provides new perspectives and insights into general practitioners views and experiences which support appropriate management of patients with multimorbidity. Overall characteristics of general practice thereby accommodate the clinical challenges posed by the group of patients with multimorbidity in an increasingly specialized healthcare system.